Practice guidelines for evaluating new fever in critically ill adult patients. Task Force of the Society of Critical Care Medicine and the Infectious Diseases Society of America.

OBJECTIVE: The development of practice guidelines for evaluating adult patients who develop new fever in the intensive care unit (ICU) for the purpose of guiding clinical practice. PARTICIPANTS: A task force of 13 experts in disciplines related to critical care medicine, infectious diseases, and surgery was convened from the membership of the Society of Critical Care Medicine and the Infectious Disease Society of America. EVIDENCE: The task force members provided personal experience and determined the published literature (articles retrieved with use of MEDLINE or textbooks) from which consensus would be sought. The published literature was reviewed and classified into one of four categories, according to study design and scientific value. CONSENSUS PROCESS: The task force met several times in person and twice monthly by teleconference over a 1-year period to identify the pertinent literature and arrive at consensus recommendations. Consideration was given to the relationship between the weight of scientific evidence and the experts\u27 opinions. Draft documents were composed and debated by the task force until consensus was reached by nominal group process. CONCLUSIONS: The panel concluded that because fever can have many infectious and noninfectious etiologies, a new fever in an adult patient in the ICU should trigger a careful clinical assessment rather than automatic orders for laboratory and radiological tests. A cost-conscious approach to obtaining diagnostic studies should be undertaken if they are indicated after a clinical evaluation. The goal of such an approach is to determine, in a directed manner, whether infection is present so that additional testing can be avoided and therapeutic options can be identified

Quantification of Stratospheric Ozone Recovery Due to Anthropogenic Halogens

Human release of CFCs and other ozone depleting substances (ODS) has led to a slow, steady erosion of the thickness of the global ozone layer over the past several decades. The ozone layer has begun to recover due to actions taken under the Montreal Protocol, which has led to a decrease in the atmospheric abundance of ozone depleting substances. Yet, unreported emissions of CFC-11 have led to a slower than expected decline, and there has been a rise in the atmospheric abundance of chlorinated very short lived (VSL) compounds not regulated under the Montreal Protocol. In this presentation, we examine time series of ozone and halogens from a variety of observational platforms to quantify the attribution of the change in stratospheric ozone that is due to halogens. Our focus is on the extra-polar region: i.e., the state of the ozone layer between 55S and 55N where the vast majority of the world’s population resides. We will quantify the effect of continued release of CFC-11 and the presence of chlorinated VSL species on the recovery of the ozone layer. Additionally, we will use atmospheric observations to evaluate several proposed formulations for defining the quantity known as “Equivalent Effective Stratospheric Chlorine” (EESC) and assess the impact of these formulations on the projected recovery of the ozone layer

Analysis of trends in total stratospheric ozone

Time series of total column ozone have exhibited unusual, unexpected behavior over the past few years. In year 2016, total ozone was lower than expected based on some forecasts that utilize the time evolution of equivalent effective stratosphere chlorine (EESC). Conversely, total column ozone exhibited a sharp rise in 2017. The existence of a new formulation (i.e., Engel et al., ACP, 2017) for the fractional release factors (FRFs) used to find EESC for mid-latitude lower stratospheric air parcels, the contribution of very short-lived chlorine and bromine compounds to EESC, as well as possible temporal variations in tropospheric column ozone compound the difficulty in establishing a quantitative relationship between the time evolution of EESC and stratospheric ozone. This presentation will consist of an analysis of the ~40 year record of total column ozone measured from space (e.g., version 8.6 of the NASA SBUV Merged Ozone Data Set at the time of abstract submission), along with: a) stratospheric chlorine loading from various satellite instruments as well as the long-term ground-based measurement from Jungfraujoch, Switzerland; b) various other quantities that affect the long-term evolution of stratospheric ozone (e.g., total solar irradiance, stratospheric optical depth, quasi-biennial oscillation of the direction of tropical stratospheric winds) c) estimates of tropospheric column ozone to assess our understanding of trends in total stratospheric ozone. Preliminary results indicate better quantitative understanding is attained for the new FRFs, which lead to a more gradual recovery of total stratospheric ozone than is found using the old FRFs. Reference: Engel, A. et al., ACP, 18, 601619, doi:10.5194/acp-18-601-2018, 2018

Practice Parameters for Evaluating New Fever in Critically Ill Adult Patients. Task Force of the American College of Critical Care Medicine of the Society of Critical Care Medicine in Collaboration with the Infectious Disease Society of America.

OBJECTIVE: To develop practice parameters for the evaluation of adult patients who develop a new fever in the intensive care unit (ICU) for the purpose of guiding clinical practice. PARTICIPANTS: A task force of 13 experts in disciplines related to critical care medicine, infectious diseases, and surgery was convened from the membership of the Society of Critical Care Medicine, and the Infectious Disease Society of America. EVIDENCE: The task force members provided the personal experience and determined the published literature (MEDLINE articles, textbooks, etc.) from which consensus would be sought. Published literature was reviewed and classified into one of four categories, according to study design and scientific value. CONSENSUS PROCESS: The task force met several times in person and twice monthly by teleconference over a 1-yr period of time to identify the pertinent literature and arrive at consensus recommendations. Consideration was given to the relationship between the weight of scientific evidence and the experts\u27 opinions. Draft documents were composed and debated by the task force until consensus was reached by nominal group process. CONCLUSIONS: The panel concluded that, because fever can have many infectious and noninfectious etiologies, a new fever in a patient in the ICU should trigger a careful clinical assessment rather than automatic orders for laboratory and radiologic tests. A cost-conscious approach to obtaining cultures and imaging studies should be undertaken if it is indicated after a clinical evaluation. The goal of such an approach is to determine, in a directed manner, whether or not infection is present, so additional testing can be avoided and therapeutic options can be made